CONTINUING EDUCATION ATTENDANCE REPRINT FORM

CONTINUING EDUCATION ATTENDANCE REPRINT FORM
*All document requests must be accompanied by a $10.00 fee in U.S. funds before processing.

*Payment is accepted in the form of checks, Master Card, Visa, or Discover

*PIMS is not responsible for incomplete or incorrect information

*Please allow up to 3 business days for processing
Person Requesting Document
Name*

First NameMiddle InitialLast Name
Former Name (If Applicable)

First NameLast Name
E-mail
example@example.com
Phone Number

Area CodePhone Number
Current Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Type of Original Document Requested*
Enter a brief description
Date of Original Document

MonthDayYear
Date
Document Will Be Forwarded To:
Name*

First NameMiddle InitialLast Name
How would you like your document sent? (Pick one)*
Select
Enter your delivery information here
Email, Fax, or Full Address
Signature

Clear
The signature on the above line constitutes legal consent for release of the requested document AND also serves as legal authorization to charge a $10.00 fee per document to the credit card for which information is provided and entered directly below.

Continuing Ed Form*

USD$10 fee per document

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country